What are the treatment options for tinnitus?

Treatment Options for Tinnitus

For patients with persistent, bothersome tinnitus, cognitive behavioral therapy (CBT) is strongly recommended as the most effective evidence-based treatment for improving quality of life. 1, 2

First-Line Treatment Approaches

• Hearing aids should be recommended for patients with hearing loss and tinnitus, even if the hearing loss is only mild or unilateral 3, 1
• Sound therapy may be recommended as a management option for persistent tinnitus, providing symptomatic relief 3
• Education and counseling are essential components of tinnitus management for all patients 1

Diagnostic Classification to Guide Treatment

• Tinnitus should be classified as pulsatile or non-pulsatile, and primary or secondary to guide appropriate treatment 1
• Pulsatile tinnitus almost always requires imaging evaluation to identify potentially treatable vascular causes 1, 4
• A comprehensive otologic examination is necessary to identify potential vascular retrotympanic masses 1

Treatments Not Recommended

• Antidepressants, anticonvulsants, anxiolytics, or intratympanic medications should not be routinely recommended for primary treatment of persistent tinnitus 3
  • These medications have insufficient evidence to justify routine use and may have significant side effects or even worsen tinnitus 3
• Dietary supplements including Ginkgo biloba, melatonin, zinc, or other supplements should not be recommended 3
  • Multiple studies have failed to demonstrate consistent benefit from these supplements 3

Special Considerations

• Patients with unilateral tinnitus require more thorough evaluation, including imaging studies 1, 5
• Patients with severe anxiety or depression related to tinnitus require prompt identification and intervention due to increased suicide risk 1, 6
• For tinnitus relieved by neck pressure, evaluation for underlying vascular abnormalities is recommended 4

Treatment Algorithm

1. Determine tinnitus characteristics:

   • If pulsatile: Imaging evaluation is required (CT temporal bone and/or CT angiography) 1, 4, 5
   • If non-pulsatile: Proceed with audiologic evaluation 1, 2

2. Address any underlying treatable conditions:

   • For vascular abnormalities: Targeted treatment of the specific condition 4, 5
   • For hearing loss: Hearing aid evaluation 3, 1

3. For persistent, bothersome tinnitus:

   • First-line: Cognitive Behavioral Therapy (CBT) 3, 1, 2
   • Consider sound therapy as an adjunctive treatment 3
   • Provide education and counseling about tinnitus 1

Treatment Efficacy

• CBT has the strongest evidence for improving quality of life in tinnitus patients 3, 1
• Hearing aids can provide significant relief for patients with associated hearing loss 3, 1
• Sound therapy and tinnitus retraining therapy may provide symptomatic relief, though evidence is less conclusive 2, 7
• No medication has consistently demonstrated efficacy in eliminating tinnitus symptoms 8, 2
• For severe cases that have failed other treatments, transcranial magnetic stimulation may be considered as an emerging option 8

Common Pitfalls to Avoid

• Failing to identify potentially dangerous causes of tinnitus, particularly with unilateral or pulsatile tinnitus 1, 4, 5
• Prescribing medications without clear evidence of benefit that may cause side effects or worsen tinnitus 3
• Recommending dietary supplements that lack evidence of efficacy 3
• Neglecting to address psychological aspects of tinnitus, which can significantly impact quality of life 1, 6
• Overlooking mild hearing loss that could benefit from hearing aid intervention 3, 1